Student Enrollment Form

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1 Has student ever attended another Tennessee Public School? Yes No Last School Attended Student Enrollment Form Has student ever attended a Shelby County (or Memphis City) school? Yes No School Name Address City State School Insurance: Accept Decline If student insurance is accepted, parent must complete insurance enrollment form and pay premium. Student Social Security Number Rev 7-13 Student s Legal Last Name First Name Middle Name Birth Date (mm/dd/yyy) Generation (Jr, II, etc.) - - Gender Federal Ethnic Category: Male Hispanic or Latino Female Not Hispanic or Latino Federal Race Category: Mark one or more races to indicate what you consider your child to be. (Even if Hispanic or Latino has been chosen for ethnicity, the child must be recorded as being one or more of the following races.) Asian White American Indian or Alaska Native Native Hawaiian and Other Pacific Islander Black/African-American Grade Level Student s Physical Address (Address of Parent/Legal Guardian) Street Number Street Name Apartment City State Zip Parent/Legal Guardian #1 Title (Mr., Mrs, etc.) Last Name First Name Middle Name Generation Preferred Language English Spanish Other Translator Needed? Yes No Home Phone Work Phone Cell Phone Student Mother Both Pick-up phrase: Relationship Lives With Father Other Employed By Federal Employee Yes No Parent/Legal Guardian or Other Contact #2 Title (Mr., Mrs, etc.) Last Name First Name Middle Name Generation Preferred Language English Spanish Other Translator Needed? Yes No Home Phone Work Phone Cell Phone Student Mother Both Pick-up phrase: Relationship Lives With Father Other Employed By Federal Employee Yes No Emergency Contact #1 Title (Mr., Mrs, etc.) Last Name First Name Middle Name Generation Preferred Language English Spanish Other Translator Needed? Yes No Home Phone Work Phone Cell Phone Relationship List siblings attending Shelby County Schools Pick up phrase: Name Birth Date Gender Grade School Are there any Legal Alerts the school needs to be aware of? Yes No If Yes, please explain and provide appropriate documents (for example, court orders). Has the student ever been enrolled in a Special Education/Resource/504/Gifted Program? Yes No If yes, what type of program? Where? When? Student s Birth Place (City) Birth State Birth Country If Immigrant, Date Entered U.S. Year Started School First Date Enrolled in U.S. School (mm/dd/yyyy) (yyyy) (mm/dd/yyyy) Mother s Maiden Name Birth County Birth City Is English primary language spoken by student? Yes No Is English language limited? Yes No List Home Language

2 Formulario de Matricula del Estudiante El Estudiante ha asistido a una Escuela Pública en Tennessee? Si No El Estudiante ha asistido a Las Escuelas del Condado de Shelby (o Ciudad de Memphis)? Si No Ultima Escuela que Asistió Nombre de la Escuela Dirección Ciudad Estado Seguro de Salud Escolar: Acepto No Acepto Si acepta el seguro de salud, los padres deben completar el formulario de inscripción y pagar la prima Número del Seguro Social Sexo Masculino Femenina - - Categoría Federal de Etnicidad: Hispano o Latino No Hispano o Latino Apellido Legal del Estudiante Primer Nombre Segundo Nombre Fecha de Nacimiento (mes/día/año) Federal Race Category: Marque una o más razas para indicar lo que usted considera que raza es. (Aunque Hispano o Latino ha sido marcado por etnicidad, su hijo/a debe ser registrado con una o más de las siguientes razas.) Asiático Blanco Dirección Físico del Estudiante (Dirección de los Padres/Guardianes Legal) Indio Americano o Nativo de Alaska Nativo de Hawái u Otras Islas del Pacifico Negro/Africano-Americano Generación (Jr, II, etc.) Nivel del Grado Rev 7-13 Número de Calle Nombre de Calle Apartamento Ciudad Estado Código Postal Padre de Familia/ Guardián Legal #1 Título (Sr., Sra, etc.) Apellido Primer Nombre Segundo Nombre Generación Idioma Preferida Inglés Español Otro Necesita Intérprete? Si No Teléfono de Casa Relación Teléfono del Trabajo Estudiante Vive con Madre Padre Teléfono Celular Los Dos Otro Correo Elec. Contraseña para recogerlo: Empleado por: Empleado Federal? Si No Padre de familia/guardián Legal o Otro Contacto #2 Título (Sr., Sra, etc.) Apellido Primer Nombre Segundo Nombre Generación Idioma Preferida Inglés Español Otro Necesita Intérprete? Si No Teléfono de Casa Relación Teléfono del Trabajo Estudiante Vive con Madre Padre Teléfono Celular Los Dos Otro Correo Elec. Contraseña para recogerlo: Empleado por: Empleado Federal? Si No Contacto Emergencia #1 Título (Sr., Sra, etc.) Apellido Primer Nombre Segundo Nombre Generación Idioma Preferida Inglés Español Otro Necesita Intérprete? Si No Teléfono de Casa Relación Teléfono del Trabajo Contraseña para recogerlo: Teléfono Celular Correo Elec. Ponga en lista los hermanos que asisten a las Escuelas del Condado Shelby Nombre Fecha de Nacimiento Genaro Grado Escuela Hay alertas legales que la escuela tiene que saber? Si No Si marca Si, explique y provee documentos apropiados (por ejemplo, órdenes judiciales). Ha sido el estudiante matriculado en una escuela de Educación Especial/Recursos/504/Programa de Superdotados? Si No Si marca Si, qué tipo de programa? Donde? Cuando? Lugar de Nacimiento (Ciudad) Estado País Si es Inmigrante, Fecha de Entrada a los EE.UU Año que empezó la escuela Fecha inscrito por primera vez en una escuela de EE.UU (mes/día/año) (año) (mes/día/año) Nombre y Apellido de la Madre País de Nacimiento Ciudad de Nacimiento Es Inglés el idioma principal del estudiante? Si No Inglés Limitado? Si No Idioma Materna

3 Household Information Survey (Please provide only one survey per household) ADDRESS Parent Name: Street: City: State: Zip: STUDENT NAME(S) ATTENDING SCHOOL(S) Do not fill out this section. For School Use Only: Student ID: Y N Student ID: Y N Student ID: Y N Student ID: Y N Student ID: Y N Student ID: Y N Please check TWO boxes below: 1) Column 1 that indicates the number of people in your household; and 2) Column 2 that represents your annual income. 3) Both check marks must be in the same row. Household Size Annual Gross Income: 1 Between $0 - $21,590 OR Above $21,590 2 Between $0 - $29,101 OR Above $29,101 3 Between $0 - $36, 612 OR Above $36,612 4 Between $0 - $44,123 OR Above $44,123 5 Between $0 - $51,634 OR Above $51,634 6 Between $0 - $59,145 OR Above $59,145 7 Between $0 - $66,656 OR Above $66,656 8 Between $0 - $74,167 OR Above $74,167 SIGNATURE An adult household member must sign the application. I certify (promise) that all information on this application is true and that all income is reported. I understand that the school will receive federal and state funding based on the information provided. I understand that school officials may verify (check) the information. Sign here: Date:

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5 SHELBY COUNTY SCHOOLS STUDENT RESIDENCY QUESTIONNAIRE/HOMELESS AFFIDAVIT This document is intended to address the McKinney-Vento Homeless Assistance Act. Your answers will help determine documents necessary to enroll your student. Student: Sex: M F Birth Date: / / Grade: Last Name First Name Day Month Year Do you and your student live in a fixed, regular adequate nighttime residency? (If Yes stop here. You must provide proof of homeownership or rental documents along with two current utility bills in your name as proof of residency.) declare that my family meets one of the following conditions for the McKinney-Vento Homeless Assistance Act: (Please check all that apply). 1. Lack a fixed, regular nighttime residence temporarily live with another family in a house, mobile home, or apartment because I cannot afford housing (Shared Resident Affidavit required.): Live in a Motel/Hotel (Hotel/Motel Receipt required.) Live in an emergency shelter, transitional shelter, or domestic violence shelter. Live in a car, trailer, park, or campground. Other location: 2. The student lives with: 3. I am: One Parent Two Parents Legal Guardian (Proof of Guardianship required) Unaccompanied Youth The parent/legal guardian of the above-named student Other: The district will actively investigate all cases where it has reason to believe false information has been provided on an affidavit; including the use of private investigators/scs Security to verify residency status (verification may include home visits). The district may refer cases in which false information has been provided to counsel for Shelby County Schools for further actions and/or file civil action to recover damages incurred as a result of providing false information. Investigations that reveal students have enrolled on the basis of providing false information will lead to immediate withdrawal from the district. I declare under penalty of perjury under the laws of this state that the information provided here is true and correct and of my own personal knowledge. Signature: Printed Name: Date: Address/Current Location: Street City Zip Mailing Address: Street City Zip Telephone: Cell Phone: Other Phone: For Office Use Only: School Assigned: Information Verified by: Date: Shelby County Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, age, gender, or disability.

6 SHELBY COUNTY SCHOOLS - CUESTIONARIO DE RESIDENCIA DEL ESTUDIANTE / DECLARACIÓN JURADA PARA PERSONAS SIN HOGAR Este documento tiene por objeto abordar la Ley de Ayuda para Personas sin Hogar McKinney-Vento. Sus respuestas ayudarán a determinar los documentos necesarios para inscribir a su hijo. Alumno: Sexo: M F Fecha de Nacimiento: / / Grado: Apellido Nombre Día Mes Año Viven usted y el estudiante en una residencia nocturna fija, adecuada, regular? (Si responde "Sí", pare aquí. Usted debe proporcionar prueba de la propiedad de vivienda o documentos de alquiler junto con dos facturas de servicios públicos actuales en su nombre como prueba de residencia.) 1. Declaro que mi familia cumple con una de las siguientes condiciones para la Ley de Ayuda a Personas sin Hogar McKinney- Vento: (Favor de marcar todas las que correspondan) Carecer de una residencia fija, regular. Vivir temporalmente con otra familia en una casa, casa móvil, o un apartamento, porque no puedo pagar la vivienda. Vivir en un motel / hotel Vivir en un refugio de emergencia, vivienda de transición, o refugio de violencia doméstica. Vivir en un coche, caravana, parque, o campamento. Otro lugar: 2. El Alumno(a) vive con: Uno de los padres de familia Padre y madre Tutor Legal (Prueba de tutela requerida) 3. Yo Soy: El padre/madre/tutor legal del estudiante mencionado arriba Joven no acompañado Otro: El Distrito investigará activamente a todos los casos en los que haya razones para creer que ha sido proporcionada información falsa en una declaración jurada; incluyendo el uso de investigadores privados / Seguridad de SCS para verificar el estatus de residencia (la verificación puede incluir visitas a domicilio). El distrito puede remitir los casos en los que se haya otorgado información falsa a los abogados de las Shelby County Schools para futuras acciones y / o presentar una acción civil para recuperar daños sufridos como resultado de proporcionar información falsa. Las investigaciones que revelen estudiantes que han sido inscritos a base a información falsa dará lugar a darlos de baja inmediatamente de la escuela. Declaro bajo pena de perjurio bajo las leyes de este estado que la información aquí proporcionada es verdadera y correcta, y de mi propio conocimiento. Firma: Nombre en letras de molde: Fecha: Dirección / Lugar actual: Calle Ciudad Código Postal Dirección de Correo: Calle Ciudad Código Postal Teléfono: Celular: Otro teléfono Para el uso exclusivo de la oficina: Escuela Asignada: Información Verificada por: Fecha: Shelby County Schools ofrece oportunidades educativas y de empleo sin considerar raza, color, credo, origen nacional, religión, edad, sexo, o discapacidad.

7 TEXTBOOK RULES Rules Under Which Textbooks Are Issued To Students Of Memphis School of Excellence I. All Textbooks Are Property of The Board of Education, Memphis School of Excellence. II. Textbooks Must Not Be Damaged. Some damages to textbooks are as follows: A. One or more pages of content missing. B. Water soaked, causing backs and pages to be swollen or molded. C. Physically marked with any pencil, pen, crayon, etc., on outside, inside or ends, or on any page. D. Defaced or marred, such as broken, cut, or smeared backs or pages, etc. III. Penalty for Lost Textbooks The student will pay as follows: A. Full replacement price, if new when issued. B. Three/fourths (3/4) of the replacement price, if used when issued. IV. Penalty for Textbooks Damaged Beyond Use The student will pay as follows: A. Full replacement price, if new when issued. B. Three/fourths (3/4) of the replacement price, if used when issued. C. Books so damaged will become the property of the student after payment. V. Penalty for Damaged Textbooks Which Are Still Usable Principals may collect for damages at their discretion. VI. Sanctions A. Additional textbooks shall not be issued until restitution is made. B. All report cards, certificates of progress or diplomas will be withheld until restitution is made. C. A suspension (In School, Home or Board) may be used in extreme circumstances. I certify that I have read and understand the above rules and agree to comply with them. Date Student s Name Parent or Guardian Memphis School of Excellence does not discriminate in its programs or employment on the basis of race, color, religion, national origin, disability, sex, age or genetics. For more information, please contact the Office of Equity Compliance at (901)

8 MEDIA RELEASE FORM School Date Dear Parent or Guardian: Throughout the school year, the media may visit your school to cover special events. Shelby County Schools may also wish to use your childʼs photograph, likeness, voice or student work for promotional and educational reasons, such as in publications, posters, brochures and newsletters; on the district website, radio station or Cable TV channel; or at community fairs or other special district events. Before your childʼs photograph, likeness, voice or student work can be used by the media or by the school district, you must give your permission. Please sign and return this form to your childʼs school, indicating your preference. Thank you for your cooperation. o I give my permission for my child to be filmed/photographed/interviewed by the media during school events and for the district to use my childʼs photograph/work/voice for promotional and educational purposes. Parent/Guardian signature Date o I do not give my permission for my child to be filmed/photographed/interviewed by the media during school events and for the district to use my childʼs photograph/work/voice for promotional and educational purposes. Parent/Guardian signature Date Studentʼs Name (please print) If you have any questions about this form, please call your school or the Shelby County Schools Office of Communications and Broadcast Services at

9 ENGLISH Migrant Education Program Occupational Survey STATE OF TENNESSEE DEPARTMENT OF EDUCATION BILL HASLAM 6 th FLOOR, ANDREW JOHNSON TOWER KEVIN HUFFMAN GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER NASHVILLE, TN Student Information: Last Name First Name Gender Race District School: Grade Year Migrant students may be eligible for additional services and assistance. Please answer the following questions and return the survey to the school so that we can determine if your child qualifies for migrant services. 1. Did you or someone in your family come to Tennessee looking for temporary or seasonal work in agriculture, fishing, dairy, or in any plant processing foods (examples: working with tobacco, tomatoes, cotton, strawberries, nurseries, trees, pork, chickens, vegetables, etc)? YES NO If yes, please mark which member of the family does or did this kind of work: Mother Father Children Other 2. Do you or someone in your family currently work in agriculture fishing, dairy, or in any plant processing foods (examples: working with tobacco tomatoes, cotton, strawberries, nurseries, trees, pork, chicken, vegetables, etc). YES NO If yes, please mark which member of the family does this kind of work: Mother Father Children Other 3. If your current job is not temporary work in agriculture or fishing, did you or someone in your family work in a temporary or seasonal agriculture of fishing in the last 3 years? YES NO If yes, where? City State Country If you answered yes to any of the questions above, please answer questions 4, 5 and How long have you been in this county? months years 5. What is your current address? 6. What is your current telephone number? NOTE TO THE LEA: PLEASE RETURN ONLY SURVEYS WITH ONE OR MORE YES RESPONSES TO JESSICA CASTANEDA 4660 HILLS CREEK ROAD, MCMINNVILLE TN CALL IF YOU HAVE QUESTIONS. TN form #ED-5438

10 SPANISH STATE OF TENNESSEE DEPARTMENT OF EDUCATION BILL HASLAM 6 th FLOOR, ANDREW JOHNSON TOWER KEVIN HUFFMAN GOVERNOR 710 JAMES ROBERTSON PARKWAY COMMISSIONER NASHVILLE, TN Programa de Educación para Estudiantes Migrantes Encuesta Ocupacional Nombre del Estudiante: Nombre Apellido Sexo Raza Distrito: Escuela Grado Aňo El Programa de Educación para estudiantes migrantes a través del Departamento de Educación Pública del Estado provee servicios de apoyo a los niños y familias que se han mudado Tennessee en los últimos 3 años. Para calificar en el programa las familias deben de haberse mudado de un lugar a otro en busca de trabajo temporal en agricultura o pesca. El Programa registra a niños y jóvenes entre las edades de 3 a 21 años (asistan o no a la escuela). Agradecemos que nos ayuden a determinar si su niňo o pariente califica para recibir servicios en este programa. Por favor, conteste las siguientes preguntar y entréguelas a la escuela. 1. Vino usted o alguien en su familia a buscar trabajo temporal en agricultura o en el campo (ejemplo: tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc.), o de pesca (empacadora de pescados o mariscos) o alguna planta procesadora de alimentos (cerdos, pollos, vegetales, etc.)? SI NO Si su contestación es si por favor indique que miembro de su familia hizo esta clase de trabajo. Madre Padre Hijos Otros 2. Ud. o alguien de su familia trabaja ahora en agricultura (ejemplos : tabaco, papas, algodón, fresas, viveros, trabajo con árboles, etc. ) o en una procesadora de pescado, lechería, o procesando comida (puerco, pollo, vegetales, etc.) SI NO Si su contestación es si por favor indique que miembro de su familia trabaja en esta clase de trabajo. Madre Padre Hijos Otros 3. Si su trabajo actual no se relaciona a la agricultura y pesca, Usted o algún miembro de su familia ha trabajado en dichas actividades en los últimos 3 aňos? SI NO Dónde? Ciudad Estado País Si usted contestó "sí" a alguna de las preguntas anteriores, favor de contestar las preguntas 4, 5 y Hace cuánto tiempo se mudó a este condado? Mes Año 5. Cuál es su dirección actual? Ciudad Código Postal Teléfono 6. Cuál es su numero del teléfono actual? NOTE TO THE LEA: PLEASE RETURN ONLY SURVEYS WITH ONE OR MORE YES RESPONSES TO JESSICA CASTANEDA 4660 HILLS CREEK ROAD, MCMINNVILLE TN CALL IF YOU HAVE QUESTIONS. TN form # ED-5438-S

11 Memphis City Schools Primary Home Language Identification Form FORM NO Revised 7-10 This form must be completed by the parent or legal guardian during registration on ALL NEW STUDENTS. Date Student Sex Date of Birth School Grade Student # Home Telephone The native/home language of each student must be recorded in his/her permanent record. Please answer the following questions about your childʼs language background: 1. What was the first language your child learned to speak? 2. What language does your child speak most often outside of school? 3. What language does your child use to speak to adults in your home? Collected for funding purposes only Was this child born in the United States? Yes No If No, complete the following: a. Country of birth b. Date entered United States Month/Day/Year c. Date entered U. S. schools Month/Day/Year d. Does your child have Refugee Status? Yes No Signature of Parent/Guardian Signature of Questioner This section is to be completed only for students who answered any questions 1-3 with a language other than English. a. In what language do you want notices sent to you from the school? b. LAU Category of student (check one) Category A - speaks only the language other than English Category B - speaks mostly the language other than English Category C - speaks English and the other language equally well Category D - speaks mostly English Category E - speaks only English Send a copy of this form to the ESL Program Office (phone ). Place the original in the student's permanent record. Memphis City Schools does not discriminate in its programs or employment on the basis of race, color, religion, national origin, disability, sex, age or genetics. For more information, please contact the Office of Equity Compliance at (901) /14507

12 Memphis City Schools Formulario Principal Para Identificar El Idioma Del Hogar Este formulario deberá ser completado por los padres o un representante legal durante la matriculación para TODOS LOS ESTUDIANTES NUEVOS. Fecha: Nombre del estudiante: Sexo Fecha de Nacimiento: Escuela: Grado Número del estudiante: Número de Teléfono El idioma natal ó del hogar de cada estudiante debe ser registrado en su matrícula permanente. Favor de contestar las siguientes preguntas acerca de los antecedentes del idioma de su hijo(a): 1. Cuál fue el primer idioma que su hijo(a) aprendió a hablar? 2. Qué idioma habla más su hijo(a) fuera de la escuela? 3. Qué idioma usa más su hijo(a) para hablar con adultos en su hogar? Estrictamente por razones para recibir fondos, necesitamos la siguiente información El estudiante nació en los Estados Unidos? Si No Si la respuesta es No, favor de contestar lo siguiente: a. País de nacimiento: b. Fecha de entrada a los Estados Unidos: c. Fecha de entrada a la escuela en los Estados Unidos: d. Su hijo(a) tiene el estado de refugiado(a)? Si No Firma del Padre o Representante Legal Firma del Preparador Esta sección debe ser completada únicamente para aquellos estudiantes que respondieron a una de las preguntas1 al 3 con un idioma que no sea el inglés. a. En que idioma quisiera usted que le envíen notificaciones de su escuela? b. Categoría LAU del estudiante (favor de marcar uno) Categoría A únicamente habla su idioma, no habla el inglés Categoría B por la mayor parte habla su idioma más que el inglés Categoría C habla tanto su idioma como el inglés igualmente Categoría D habla por la mayor parte el inglés Categoría E habla únicamente el inglés Send a copy of this form to the ESL Program at the Fairview Administration office, Telephone # and place the original in the student s permanent record. Las escuelas de la Ciudad de Memphis no discriminan en sus programas o empleo en las bases de raza, color, religión, origen nacional, minusválidos / incapacidad, sexo o edad. Primary Home Language Form/Vietnamese/ESL Office 7/01/07 English Form No.14507

13 School Address: 4450 S Mendenhall Rd Memphis, TN Tel: (901) Fax: (901) MEMPHIS SCHOOL OF EXCELLENCE STUDENT AGREEMENT It is important that I work to the best of my ability. Therefore, I shall strive to do the following: Attend school regularly. Arrive at school on time and attend all classes daily. Wear uniforms every day. Come to school each day with pens, pencils, paper, and other necessary tools for learning. Perform at my highest level of learning each day. Complete and return homework assignments. Observe regular study hours. Respect others. Follow all rules that govern student conduct at Memphis School of Excellence. Observe and follow classroom policies and procedures. Take responsibility for my actions and grades and to cooperate with others that I may receive a quality education. Student Name: Grade: Signature:

14 School Address: 4450 S Mendenhall Rd Memphis, TN Tel: (901) Fax: (901) MEMPHIS SCHOOL OF EXCELLENCE PARENT/GUARDIAN AGREEMENT Memphis School of Excellence has jointly developed and outlines how parents/school/staff/students will share the responsibility for improving student academic achievement by providing high quality curriculum and instruction in a supportive and effective learning environment and how the school and parents will build a partnership to hold children achieve. It s important that I take a more responsible role for supporting my child s learning. Therefore, I shall strive to do the following: (Any person who is interested in helping this student may sign in lieu of the parent) Monitor my child s attendance and punctuality on a daily basis. Support the school in all of its efforts on behalf of my child, e.e., proper discipline, adherence to regulations, plans and programs for learning. Establish a time for homework and review it regularly for completion. Provide a quiet, well-lighted place for study. Encourage my child s efforts and be available for questions. Check with my child for information sent home, promptly read and sign it. Maintain an on-going and positive line of communication between parents and myself. Read with child and let my child my see me read. Make certain that my child wears the required uniform and wear it properly. Volunteer, participate, and observe in my child s class. Develop a partnership with the school to help my child achieve the state s high standards. Teach social skills to promote positive interactions with all. Provide necessary supplies for my child s instruction. Communicate with the teachers frequently to discuss my child s progress and behavior. Attend scheduled parent meetings, conferences, and workshops. Parent Name: Signature Parent Name: Signature

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16 Forma de Notificación de Sanciones Escuelas del Condado de Shelby Dorsey E. Hopson, II Esq. Superintendente Padre de Familia/ Tutor Nombrado por el Corte/ Cuidador: La Política del Distrito requiere una prueba válida de residencia para todos los estudiantes. Por favor, lea atentamente la siguiente información antes de firmar y completar la declaración jurada. Atentamente, Dorsey E. Hopson, II Esq. Superintendent Las iniciales de cada persona interesada son necesarias después de cada declaración. Shelby County Schools investigará activamente a todos los casos en los que tiene razones para creer que información falsa se ha proporcionado en una declaración jurada; incluyendo el uso de investigadores privados / seguridad de SCS para verificar el estatus de residencia (verificación puede incluir visitas al hogar). (Iniciales) El distrito puede remitir los casos en que se haya proporcionado información falsa a los abogados de Shelby County Schools para la acción y / o iniciar acción civil para recuperar los daños sufridos como resultado de proporcionar información falsa. (Iniciales) Las investigaciones que revelan que los estudiantes se han inscrito en la base de proporcionar información falsa darán lugar a la retirada inmediata del Distrito. (Iniciales) Firma del Padre de Familia/Tutor Fecha Firma del Residente Principal /Dueño Fecha Shelby County Schools ofrece oportunidades educativas y de empleo sin considerar raza, color, credo, origen nacional, religión, edad, sexo, o discapacidad

17 Proof of Residence Form School Student s Name Grade According to Shelby County Board of Education Policy 6002, only students whose parents/legal guardians reside within the Shelby County Schools district may attend Shelby County Schools. Parent/Guardian Address City Home Phone Number Daytime Phone Number Zip I have provided the following items as proof of my residence bearing the address of my current residence. Please check two (2) of the following items listed below. Driver s license or other State/Government issued ID Mortgage statement or deed Public assistance/government benefits documents Lease/Rental Agreement Real Estate tax receipt Municipal water bill Most recent MLGW bill Most recent previous address Street Number and Name City State Zip According to Shelby County Board of Education Policy 6002, parents/guardians who live with another person must provide additional information to the school during registration for Shared Residency Verification. Parents who move from the address provided at registration must submit an Eligible Circumstance Request for Transfer via an electronic process. Approval must be obtained through Student Services for continued enrollment. I do solemnly declare that the information I have given is true and correct to the best of my knowledge and belief. I understand that I may be charged for the cost of my child s education if I do not live in the Shelby County School District. TCA Signed Date School Use Only Reviewed and approved by: Date of Approval If residency questions arise it will be necessary to request additional proof. Shelby County Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, sex, age, disability, or genetic information. SCS adheres to the provisions of the Family Rights and Privacy Act (FERPA).

18 Shelby County Schools Shared Residence Affidavit This form is to be completed if residency requirements cannot be provided due to the fact that the parent and child(ren) are sharing a home with another person SEVEN DAYS A WEEK YEAR ROUND. This affidavit must be re-certified through Student Services annually. All sections must be completed and signatures notarized. DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ARE INCORRECT. Evidence of false information will result in immediate withdrawal of the student(s) from school. To be completed by Parent(s)/ Guardian(s): Student: Sex: M F Birth Date: / / Grade: Last Name First Name Student: Sex: M F Birth Date: / / Grade: Last Name First Name (Please list additional students on a separate sheet.) Parent (s) Name: Last Name First Name Last Name First Name Address: Telephone: Cell Phone Other Phone: This living arrangement is: Temporary Duration: Permanent This address listed above is my only residence. I agree to notify Shelby County Schools if there is any change in the status of my residence. I understand that home visitation and/or residency verification is part of the process when residency is established by an Affidavit of Shared Residence. Signature of Parent/Legal Court Appointed Guardian TN Driver s License/ID Card Number Date TO BE COMPLETED BY HOMEOWNER: I,, declare/certify that I am the primary resident/owner at (Owner, Lease Holder, Qualified Relative, Friend, Neighbor, etc.) and that the above mentioned adult(s) and student(s) reside with me on a full- (Street) (City) (Zip) time basis (seven days a week year round.) I agree to notify Shelby County Schools if there is any change in the status of residence of the persons listed above. I understand that home visitation and/or residence verification is part of the process when residency is established by a Shared Residence Affidavit. I further agree to provide proof of my residence to Shelby County Schools. Signature of Primary Resident/Owner(s) TN Driver s License/ID Card Number Date State of Tennessee, County Of On before me, Personally appeared Name(s) of Signer(s), Place Notary Seal below who proved to me on the basis of satisfactory evidence to be the person(s) whose name(s) is/are subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their authorized capacity(ies), and that by his/her/their signature(s) on the instrument the person(s), or the entity upon behalf of which the person(s) acted, executed the instrument. I certify under PENALTY OF PERJURY under the laws of the State of Tennessee that the foregoing paragraph is true and correct. WITNESS my hand and official seal. Signature Signature of Notary Public Shelby County Schools offers educational and employment opportunities without regard to race, color, creed, national origin, religion, age, gender, disability or genetic informaiton.

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